1. Implement general nursing routine for respiratory patients.
2. Keep the indoor air fresh, well ventilated and the temperature and humidity appropriate. 3. Give the breather a semi-sitting position.
4. Give a high-protein, high-vitamin and digestible diet, and avoid spicy and gas-producing foods. Instruct patients to drink more water.
5. Observe the changes of consciousness and vital signs, blood oxygen saturation, monitor blood gas analysis when necessary, and observe the color, quantity and smell of sputum and the patient's breathing. 6. Keep the respiratory tract unobstructed. For those who are not easy to cough up due to excessive phlegm, they should be instructed to cough effectively, atomize and inhale, turn over and knock on the back, and conduct drainage when necessary; Patients with dyspnea were treated with oxygen at a flow rate of 1 ~ 3l/min. > 15 hours/day.
7, according to the doctor's advice timely and accurate application of antibiotics and asthma expectorants, theophylline drugs, should observe the presence of nausea and arrhythmia symptoms. 8. Keep the skin and mouth clean, and those who use hormone spray should pay attention to gargle in time.
9. Encourage patients to establish confidence in long-term treatment of diseases and prevent anxiety and pessimism. 10, instruct patients to avoid inducing factors, quit smoking, keep warm and prevent upper respiratory tract infection.
1 1. Guide patients to carry out respiratory function rehabilitation training: lip-contracted breathing and abdominal breathing; Guide them to adhere to long-term low-flow oxygen therapy and improve their quality of life. Pay attention to step by step during activities to avoid fatigue.
2. Respiratory medicine nursing routine
First, the nursing routine observation of spontaneous pneumothorax 1. Observe the degree of chest pain, cough and dyspnea, and contact the doctor to take corresponding measures in time.
2. Observe the patient's breathing, pulse, blood pressure and complexion changes. 3. After closed thoracic drainage, the wound should be observed for bleeding, air leakage, subcutaneous emphysema and chest pain.
Nursing measures 1. Try to avoid coughing and give cough suppressants according to the doctor's advice if necessary. 2. Reduce activities, keep the stool unobstructed, avoid holding your breath hard, and take corresponding defecation measures when necessary.
3. Patients with severe chest pain can be given corresponding painkillers according to the doctor's advice. . .
4. According to the condition, prepare articles and drugs for thoracic puncture and closed thoracic drainage, and cooperate with doctors for related treatment in time. Thoracic drainage should be carried out according to the nursing routine of thoracic drainage.
5. Give a diet with high protein and moderate crude fiber. 6. Semi-recumbent position, oxygen supply, oxygen flow rate is generally above 3L/ min.
7. Stay in bed. Health guidance 1. Diet care, eat more high-protein diet, not picky eaters, not partial eclipse, eat crude fiber food properly.
2. After the pneumothorax is cured, avoid strenuous exercise, weight lifting or weight lifting, and hold your breath within 1 month. 3. Keep the stool unobstructed, and effective measures should be taken if the stool remains unsolved for more than 2 days.
4. Prevent upper respiratory tract infection and avoid severe cough. Second, the routine nursing observation of acute upper respiratory tract infection 1. Pay attention to the changes of body temperature and breathing style.
2. Pay attention to the symptoms of complications, such as headache, tinnitus and nasal swelling. Nursing measures 1. Keep the indoor air fresh and ventilate twice a day, each time 15-30 min.
.2. Ensure that patients have proper rest, and seriously ill or elderly people should stay in bed. 3. Drink plenty of water, the amount of water depends on the patient's body temperature, sweating and climate.
Give a light and digestible diet rich in vitamins, high calories and high protein. 4. When the body temperature exceeds 38.5 degrees Celsius, give physical cooling.
Use antipyretic and analgesic tablets according to the doctor's advice when you have a high fever. Observe the effect after cooling.
Patients who sweat a lot should change their clothes in time and do a good job in cleaning and nursing their skin. 5. When shivering, keep warm.
6. Take the medicine according to the doctor's advice. Health guidance 1. Pay attention to respiratory isolation to prevent cross infection.
2. Maintain adequate nutrition, rest and exercise, and increase the body's resistance. 3. Avoid smoking.
4. Insist on washing your face with cold water to improve your body's adaptability to cold. Routine observation of pneumonia nursing 1. Measure blood pressure, temperature, pulse and breathing regularly.
2. Observe the mental symptoms, whether there is unconsciousness, lethargy and irritability. 3. Observe whether there are early symptoms of shock, such as irritability, slow response and decreased urine output.
4. Pay attention to the change of color, quality and quantity of phlegm. 5. Closely observe the effects and side effects of various drugs.
Nursing measures 1. According to the condition and doctor's advice, reasonable oxygen therapy. 2. Ensure that the intravenous infusion is unobstructed and there is no overflow, and set the central venous catheter pressure when necessary to know the blood volume.
3. Send sputum culture and blood culture according to the doctor's advice. 4. See high fever nursing routine for high fever nursing.
Chest pain, cough and expectoration can be treated symptomatically. 6. Diet care, giving a high-nutrition diet, encouraging drinking more water, and giving a light and digestible semi-liquid diet to critically ill and high fever.
7. Keep warm and stay in bed as much as possible. Health guidance 1. Exercise and strengthen your body resistance.
2. Avoid catching a cold during the season change. 3. Avoid excessive fatigue and go to public places less when a cold is prevalent.
4. Prevention and treatment of upper respiratory tract infection as soon as possible. Four, respiratory failure nursing routine observation points 1. Consciousness, blood pressure, respiration, pulse, body temperature, skin color, etc.
2. Whether there are symptoms of pulmonary encephalopathy and shock. 3. Urine volume and stool color, with or without upper gastrointestinal bleeding.
4. The effects and side effects of various drugs (especially respiratory stimulants). 5. Changes of arterial blood gas analysis and various laboratory indexes.
Nursing measures 1. Diet care, encourage patients to eat more high-protein and high-vitamin foods (patients with gastric tube placement should follow the routine of gastric tube care). 2. Keep the respiratory tract unobstructed (1) and encourage patients to cough and expectorate, and drink more water.
(2) critically ill patients turn over and pat their backs every 2~3h to help expectorate. If artificial airway is established, airway management should be strengthened, and sputum aspiration should be done mechanically if necessary.
(3) Conscious people can do atomized inhalation, 2-3 times a day, each time 10-20m3. Patients with type ⅱ respiratory failure should be given low concentration (25%-29%) flow (1-2l/min) continuous oxygen inhalation through nasal catheter. How to use the ventilator together with the respiratory center stimulant can slightly increase the oxygen concentration.
4. Critically ill patients or those who use mechanical ventilation should make intensive care records, keep the bed flat and dry, and prevent bedsores. 5. For those who use nasal mask or nasal mask pressurization to assist mechanical ventilation, do this nursing well.
6. The establishment of artificial airway (tracheal intubation or tracheotomy) in critically ill patients should be based on the nursing requirements of artificial airway. 7. The establishment of artificial airway connected with ventilator for mechanical ventilation should meet the requirements of mechanical ventilation nursing.
8. Medication nursing (1) Choose effective antibiotics to control respiratory tract infection according to the doctor's advice. .
(2) When using respiratory stimulants according to the doctor's advice, the respiratory tract must be kept unobstructed. Pay attention to the reaction after taking medicine to prevent overdose; For patients with irritability and insomnia at night, use sedatives with caution to prevent respiratory depression.
Health education 1. Teach patients to do lip contraction and abdomen breathing to improve ventilation. 2. Encourage patients to do proper housework and get out of bed as much as possible.
3. Prevent upper respiratory tract infection, pay attention to keep warm, go out less during the flu season and go to public places less. 4. It is recommended to quit smoking, seek medical attention for colds and control the aggravation of infection.
5. Strictly control the visits of accompanying guests and their families. Thank you. I hope you can adopt me.
3. Seek the key points for attention of respiratory system in Chapter II of Internal Medicine Nursing, with the best details. Thank you very much.
Chapter II Nursing care of patients with respiratory diseases Section 1 Key points of respiratory system-related knowledge 1. Anatomy, physiology and pathology: respiratory tract: nasal cavity, pharynx, larynx, trachea and bronchus; (Ventilation, clean, warm and humid air) Lung: (the main part of gas exchange) Respiratory system function: inhale oxygen and expel carbon dioxide to ensure normal metabolism and relative stability of internal environment.
Second, the nursing points of common symptoms: (1) cough and expectoration 1. Nursing evaluation: (1) Understand the medical history; (2) Observe the characteristics of cough and expectoration: the nature, timbre and rhythm of cough, the color, quality, quantity and smell of sputum, and whether it is easy to cough up; (3) Understand the accompanying symptoms and signs: the relationship with * * *, whether there is fever, chest pain, dyspnea, rales, etc. (4) Understand the treatment and related examination: What expectorant and antitussive drugs have been used; (5) Understand the patient's psychological state; Please think: What is the relationship between the color and smell of phlegm and diseases? 2. Nursing diagnosis: (1) respiratory tract cleaning is ineffective: it is related to ineffective cough, phlegm, fatigue, chest pain and disturbance of consciousness; (2) There is a risk of suffocation: it is related to disturbance of consciousness, inability to expel phlegm, and increased respiratory secretions blocking the respiratory tract; Please think: how to care for patients with cough and expectoration? 3. Nursing measures: (1) Humidify airway; (2) Turn over and buckle your back; (3) Instruct effective cough and expectoration; (4) drainage; (5) mechanical sputum aspiration; Please think about it: what methods can be taken to dilute sputum for patients with sticky phlegm who are not easy to cough up? Why do you want to turn over and buckle your back? ② Hemoptysis 1. Nursing evaluation: (1) Understand the medical history; (2) Understand the blood volume, color and characteristics: a small amount of hemoptysis: 500ml/d or 300ml/ time; (3) Observe the patient's vital signs and find asphyxia in time; (4) Understand the treatment and related examinations; (5) Understand the patient's psychological state; Thinking: How to find the symptoms of suffocation in time? 2. Nursing diagnosis: (1) Asphyxia risk: related to consciousness disorder and airway obstruction caused by massive hemoptysis; (2) Infection risk: related to blood retention in bronchus; 3. Nursing measures: (1) rest * * *: a small amount of hemoptysis: rest in repose; Massive hemoptysis: Absolute bed rest.
Assist the patient to lie flat and tilt his head to one side; (2) Avoid forced defecation and stabilize patients' mood. (3) Keep clean and comfortable: rinse the mouth for the patient in time and wipe the blood; (4) Observation of illness: Observe the characteristics of vital signs, consciousness, pupils and hemoptysis, and pay attention to whether there are signs of suffocation; Precursors of suffocation: chest tightness, suffocation, cyanosis of lip nails, pale face, cold sweat, irritability, etc.
(5) Prevention of asphyxia: Tell the patient not to hold his breath when hemoptysis occurs, keep the respiratory tract unobstructed, and prepare rescue drugs and articles (first aid articles such as sputum suction tube and tracheal intubation). (6) Asphyxiation rescue nursing: 1) Timely removal of hemoptysis in respiratory tract: ▲ Take prone position immediately with head down and feet high; ▲ Pat the back to promote the patient to cough up blood; ▲ Rapid sputum aspiration by nasal catheter, or sputum aspiration by tracheal intubation or bronchoscopy; 2) High flow oxygen inhalation; 3) establish venous access and take medicine according to the doctor's advice (hemostasis, sedation and cough); 4) Stabilize patients' mood; 【 Note: When pituitrin is used for massive hemoptysis, the dropping speed should be controlled; Hypertension, coronary heart disease, heart failure and pregnant women are prohibited] 5) Closely observe the condition and be alert to suffocation again: observe the patient's vital signs, the amount, color, nature and bleeding speed of hemoptysis.
6) Blood matching and transfusion when necessary; (3) Pulmonary dyspnea (please think about the types and causes of pulmonary dyspnea) 1. Nursing evaluation: (1) medical history; (2) Characteristics of dyspnea: changes in attack, type, breathing frequency, depth and rhythm. Assess the degree of dyspnea and hypoxia and understand the accompanying symptoms; (3) Treatment and related examination: use of antibiotics and expectorants, chest X-ray, sputum examination and arterial blood gas analysis; (5) The patient's mental state and sleep; 2. Nursing diagnosis: (1) Impaired gas exchange: related to the decrease of breathing area caused by lung diseases and airway stenosis or emphysema caused by bronchial smooth muscle spasm; (2) Inefficient breathing pattern: It is related to airway stenosis caused by bronchial smooth muscle spasm; 3. Nursing measures: (1) Rest and environment: adopt appropriate * * *, such as semi-lying position or sitting position, and set a small table opposite the bed when necessary to facilitate the patient to rest; (2) Assist the patient in expectoration: keep the respiratory tract unobstructed; (3) Correct oxygen therapy according to the doctor's advice: ▲ Generally, oxygen can be given at a normal flow rate (2~4L/min) and concentration (29%~37%) without carbon dioxide retention.
▲ Severe hypoxia without carbon dioxide retention: oxygen can be given by mask for a short time, with intermittent high flow (4~6L/min) and high concentration (45%~53%). ▲ Hypoxia with carbon dioxide retention (PaO250mmHg): oxygen can be continuously given through nasal catheter or nasal plug at low flow rate (1~ 2L/min) and low concentration (25%~29%); (4) Observe the curative effect of oxygen therapy in time: adjust the oxygen concentration and flow rate in time; (5) Pay attention to humidified oxygen: replace the disinfection oxygen inhalation device regularly to prevent cross infection; (4) Chest pain 1. Nursing evaluation: (1) Understand the medical history; (2) Understand the location, nature, degree and duration of chest pain; (3) Observe the accompanying symptoms and signs: whether it is accompanied by fever, cough, hemoptysis, dyspnea, cyanosis, shock and other discomfort.
(4) Understand the treatment and related examinations, such as the use of analgesics, chest radiographs and sputum. (5) Understand the patient's psychological state; 2. Nursing diagnosis: (1) Pain is related to chest wall diseases and visceral diseases; (2) Anxiety is related to worrying about the prognosis of the disease; 3. Nursing measures: (1) rest and * * *: take appropriate * * to ensure that patients have a good rest; (2) Stabilize patients' mood; (3) to guide the methods of relieving pain; Please think about what you have learned: how to guide patients to relieve pain? Class summary: 1. The common symptoms of respiratory system are: cough, expectoration, dyspnea, hemoptysis and chest pain. 2. The main nursing measures for respiratory symptoms are as follows: (1) promoting expectoration nursing and keeping respiratory tract unobstructed; (2) asphyxia rescue nursing; (3) Correct implementation of oxygen therapy, etc. Thoughts on acute respiratory tract infection (acute upper respiratory tract infection, acute tracheobronchitis): 1. Have you ever caught a cold in your life? How did you do? How long is the course? 2. What are the causes of colds? Acute upper respiratory tract infection: evaluation of patients: 1. Etiology and pathogenesis: 1. Virus (mostly caused by virus) 2. Bacteria: The body has arrived.
4. What are the nursing plans and evaluations of inefficient breathing patterns in respiratory department in medical common sense?
Nursing plan and evaluation of inefficient breathing mode in respiratory department.
Nursing objectives: ① The patient's airway secretion is reduced and his breathing is smooth. ② The patient has no sputum blocking the airway to affect ventilation.
③ Patients maintain normal breathing frequency and rhythm. 2) Nursing measures: ① Evaluate the patient's breathing frequency, rhythm and depth, the use of auxiliary ventilator and the degree of dyspnea.
② Monitor vital signs, blood pressure, heart rate and arrhythmia. ③ Observe the symptoms and signs of hypoxia and carbon dioxide retention.
④ Explain the importance of ventilator to patients and their families and instruct them not to adjust ventilator parameters without authorization. ⑤ Assist the patient to take a semi-recumbent position, so as to increase the efficiency of the auxiliary ventilator and promote lung inflation.
⑥ Do psychological nursing well to relieve patients' anxiety, so as to relieve dyspnea and improve ventilation. ⑦ Timely and accurate administration according to the doctor's advice, and observe the curative effect and adverse reactions.
Today, if the condition changes, the patient should be rescued in time, and relevant rescue items should be prepared quickly, and all rescue items should be done timely and accurately. 3) Effect evaluation: ① The patient did not have sputum blocking the airway and affecting ventilation. ② The patients' airway secretion decreased progressively.
③ Patients can maintain normal rhythm and frequency of spontaneous breathing.
5. How to care for respiratory tract infection?
1. environment: the temperature and humidity are suitable, and the influence of smoke and cold air is avoided.
2. Supplement nutrition and water: give a high-protein and high-vitamin diet and drink plenty of water 1500ml/d to facilitate sputum dilution. 3. Promote expectoration: In addition to using expectorants according to the doctor's advice, the following measures can be taken: (1) Guide effective cough: It is suitable for patients who are conscious and can cough.
(2) Beating the back and vibrating the chest wall: it is suitable for people who are bedridden for a long time, who are physically weak after a long illness and cannot expectorate. (3) Humidification of respiratory tract: atomized inhalation, which is suitable for people with sticky sputum and difficult to cough up.
(4) *** Drainage: It is suitable for patients with bronchiectasis and lung abscess with large amount of phlegm and good respiratory function. (5) Mechanical sputum aspiration: It is suitable for patients with excessive phlegm and weak cough reflex, especially those in coma or tracheotomy and intubation.
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